Provider Demographics
NPI:1609222835
Name:RUTLEDGE, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801
Mailing Address - Country:US
Mailing Address - Phone:863-617-9400
Mailing Address - Fax:863-688-9858
Practice Address - Street 1:411 E MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801
Practice Address - Country:US
Practice Address - Phone:863-617-9400
Practice Address - Fax:863-688-9858
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist